Transcript: Health Update
June 26, 2003
MS. PETERSON: My name is Dana Peterson, and I am serving at the Deputy Reconstruction Advisor for Iraq and Asian and Near East Bureau here at USAID. And I would like to welcome you all here today for a second in a series of public sector consultations with this one focused on health.
We see this session really as an opportunity to highlight our efforts to support the health sector in Iraq, highlighting implementation efforts over the past seven weeks. Many colleagues are here today who have been in Iraq and the region and can speak to very specific efforts and challenges in this critical sector.
Before detailing this sector, I would like to briefly describe our overall reconstruction portfolio just to provide a context for you. We presume that many of you have already had the opportunity to visit USAID's website in which there is a wealth of information on our various programs and implementation efforts. As you know, USAID is undertaking vital work to restore economically critical infrastructure, including in the power sector, major transportation systems, water and sanitation facilities, and important public buildings such as schools and health clinics.
We are addressing the delivery of essential social services, particularly health and education. And in this effort, we are working closely with United Nation organizations, including UNICEF and the World Health organization, as well as private sector partners. We are helping to improve the efficiency and accountability of government, focused at the local level, and we are trying to address the expansion of economic opportunities throughout Iraq as well.
USAID has been undertaking reconstruction efforts in meeting these objectives since around mid-April. The President declared the cessation of major combat just a little over seven weeks ago, and that's about how long we have been undergoing this effort.
In terms of setting a context for implementation efforts, work has been and will continue to be undertaken in close coordination with Coalition military forces. Security remains a concern and a challenge for implementation. It is a highly fluid situation in country, and our implementors have had to demonstrate maximum flexibility and adaptability.
Fundamental to our efforts is that we are supporting Iraqi-led initiatives and capacities and ensuring Iraqi ownership in all of our program interventions.
In terms of USAID structure in the field, we are operating like we do in dozens of countries around the world. We have a mission director, Lou Luck, who currently has approximately 30 staff focused on reconstruction, and then a number of staff who are working on humanitarian relief as well. Representatives from our Office of Foreign Disaster Assistance, Office of Food for Peace and Office of transition initiatives. So we have staff both in Baghdad as well a in Kuwait, and then various cities around Iraq.
USAID is part of the Office of Coalitional Provisional Authority, headed by Ambassador Paul Bremer. We are very integrated into that effort, and USAID is comprising approximately 1/3 of the overall reconstruction effort in country right now.
Before turning this consultation over to my colleagues, I would like to highlight that this is a session focused specifically on implementation progress in the health sector. We are not addressing Iraq reconstruction procurement issues, nor are we in a position to speak to broader administration policies.
If there are any press questions, if you could please hold those until the end, we will be able to accommodate those questions as well.
I would now like to introduce my colleagues who are here with me today. Ms. Rachel Herr has been in the field with our Disaster Assistance Response Team for a number of months, and can provide some valuable information for us on our relief and reconstruction efforts to date.
Dr. Richard Alderslade is the external relations officer with the World Health Organization. And we are waiting actually for colleagues from ABT Associates, a private sector partner of USAID, as well as from UNICEF, and so I'll introduce those individuals when they arrive at a later time.
MR. : We're here--
MS. PETERSON: Oh, sorry sir. If you could please come to the front. Dr. George Lodato? MR. : No, I replaced him.
MS. PETERSON: Oh, sorry. I'll have you introduce yourself, then, after my colleague from USAID, then World Health Organization, and then ABT Associates. So, Rachel?
MS. HERR: Thank you, Dana.
Thank you for coming, ladies and gentlemen. My name is Rachel Herr. I work for the Bureau for Asia and the Near East here at USAID. I've been in Kuwait and Iraq for the past three months as part or the Disaster Assistance Response Team, and returned about three weeks ago. And I want to talk to you a little bit about some of the background of the health situation in Iraq and then about USAID's early responses.
Iraq is not an underdeveloped country; it's a country that's been impoverished from about 20 years of neglect and lack of investment. And many of the health problems that we see in the country are as a result of this. Rather than problems that are caused by the conflict, we see a lot of problems that were caused by this lack of investment.
Some of the things that were caused by the conflicts are things like disturbances to infrastructure, such as water, electricity, and roads, looting, and an unstable security. USAID has and will address both the short-term and longer-term needs with interventions that will bring the Iraqi health system to at least where it was before.
In Iraq there are parallel problems with infectious diseases and chronic illnesses. The primary causes of mortality for children under 5 are diarrheal illnesses and acute respiratory infections, exacerbated by high rates of malnutrition. This is something that we typically see in Africa and in South Asia, but is not necessarily typical of other Middle Eastern gulf countries. Yet at the same time, we see increasing rates of chronic Illnesses, such as hypertension, diabetes, and heart disease. And we need to address both of these issues simultaneously.
It's important that while we're addressing diarrheal illness, which are the top killers of children under 5, that we also not neglect those patients who depend on dialysis, or who depend on their asthma medications. And many of these services for chronic illnesses now face shortages.
Iraq has the capacity to diagnosis and to treat complex medical problems. And so our response should not be the same as it is in countries that never had these services.
So, I'll be specific about what some of our short-term and long-term challenges are.
Then I'll talk about how USAID responded early on through the Disaster Assistance Response Team, which is part of the Office of Foreign Disaster Assistance. And then lastly, I'll introduce our Health Reconstruction Program before allowing our partners to give you more information.
Fortunately, after the war we were not faced with a humanitarian disaster, and so we were able to focus our short-term interventions on distribution and infrastructure. Immediately post-conflict, the main priority was to insure that there was minimal disruption to the health system. Very few facilities were affected by bombing or warfare. Many more were affected by systematic looting as sabotage, and opportunistic looting for profit. Looting included furniture, medicines, medical equipment, records, and in the most extreme cases, electrical wiring and plumbing.
Water and electrical systems in many areas were disrupted, and the lack of hygiene this caused risked elevating the levels of infectious diseases. Hospitals that remained functional were sometimes overwhelmed with patients seeking care, or simply didn't have the staff or equipment to treat them.
One of the biggest obstacles has been and remains the fragile security situation. This has hindered the free movement of people and goods. For example, a shortage of nursing staff in Basra was attributed to the nurses' fear to be out after dark or to go long distances to the hospitals where they worked. Warehouses cite fear of looting as an obstacle to distribution, and require the Coalition military to escort their trucks. Warehouses themselves remained vulnerable to looting.
And all of this, on top of a system that was already inequitable, which included chronic shortages of certain types of medicines, including antibiotics and drugs for cancer and chronic illnesses, and which relied on the Oil for Food Program and a centralized system for everything. Little, if anything, was invested in medical equipment or modern training of staff. Medical techniques and equipment are outdated and often unsafe. Some services are conspicuously absent, such as reproductive health and family planning services, which are barely known in the country.
These are the longer-term problems. They existed prior to the conflict and will take a while longer to solve.
How has USAID responded? Both relief and reconstruction teams were deployed to the area at the same time. Stocks of medicines, water bladders, and other humanitarian assistance equipment were prepositioned in case of emergency. But fortunately there was no major crisis, and so immediately responses focused on insuring an adequate supply of basic and chronic medicines to facilities that were still operational; and later to warehouses that could be distributed through the normal distribution system.
This was done primarily through NGO partners but also with the assistance of the Coalition military. USAID helped procure vaccines for 4.2 million children and 700,000 pregnant women. USAID also delivered water bladders and generators to hospitals to ensure a clean water supply and funded water delivery through tankers. With USAID funding, some NGO partners were able to respond early to hospital assessments and do facility repairs to lightly damaged facilities to bring them back to a functioning level. And health partners were able to closely monitor and adequately response to outbreaks of diarrheal illness, including cholera.
USAID with its partners continues to do this, continues to monitor illnesses and to ensure the functioning of facilities. But with ABT Associates, UNICEF, and WHO, we're also focusing on medium and longer-term interventions. USAID is helping to re-establish the health system by reactivating the distribution system of drugs, reactivating the health information systems, rebuilding and re-equipping existing health facilities and laboratories, and strengthening the capacity of Iraq health workers, including the addition of nursing and public health staff, and recruiting Iraqi health professionals living outside the country.
USAID is initiating public health campaigns to promote appropriate preventive and curative behaviors, and as of June 22, has helped to re-initiate regular national vaccine programs for children under 5. USAID is working under the office of the Coalition Provisional Authority, and is collaborating on the development of national health policy and strategy. We provide technical and managerial support to the Ministry of Health during this interim period, and will continue to do so after the Ministry is turned back over to the Iraqis.
Yet through all this, I also want to stress the importance of collaboration with the Iraqis, and how important they have been in keeping the health system running through this time. Ultimately it is them who are going to put this system together. It was the doctors and nurses who went back to work during the conflict and immediately after the conflict. There were doctors who stood vigil outside of their hospitals to keep looters away; there were others who took equipment, computers, and records back to their own homes for safe keeping; public health workers who continued to work' people at the warehouses who continued to record each transaction of goods and record donor contributions, even without a national or computerized system.
And the Iraqis will continue to be involved in the development of national policies and in their implementation.
With that background, I'd like to now turn this over to our partners, the first of whom is WHO, Dr. Alderslade, who will give you more information on his program. Thank you for your kind time and attention.
DR. ALDERSLADE: Good morning, ladies and gentlemen.
My name is Richard Alderslade. I work for the World Health Organization in New York. I have a background in humanitarian operation management, but I'm here today representing Dr. David Nabarro, the Executive Director of WHO, who has managerial responsibility for this program. Dr. Nabarro was in Iraq just a few days ago, and I've come here. I was with him over two or three days of fairly intensive meetings in the UN, both on the humanitarian and developmental needs in Iraq.
So that's my background, an I hope that I can contribute something to this discussion, although I think you've had a very comprehensive overview already of some of the key issues.
I'd just like to set the context a little. You've heard already that both the public health and the health system in Iraq, perhaps prior to the last decade, was at a reasonable, in fact really rather good level of sophistication for the region, but that over the last decade there has been a very substantial deterioration. And it is as the previous speaker said, very important to understand that the situation you see now is not simply the immediately result of this conflict. It is the result of a decade or more long of deterioration; deterioration in some of the classic public health indicators, such as increased maternal mortality, and increased infant mortality, a deterioration in the competence of the management of pregnancies and delivery, the almost complete absence of any modern approach to family planning and contraception has already been referred to. An increase in diarrhea and respiratory infections, an increase in malnutrition, and a substantial increase in chronic disease dependency.
It's worth just reflecting on why this deterioration occurred over the last ten years, as a background to what now needs to be done. Decreased access to potable water, deterioration in sanitation arrangements, significant increase in poverty, and a deterioration in the performance of the health system overall. The reductions in investment have already been referred to. Economic sanctions certainly played a part. And poor management of the system played a part as well.
And recently user charges were introduced with notorious effect on equity and distribution of services within the population.
The Oil for Food Program has already been referred to, introduced in 1996. This played a part, and I think a significant part, in alleviating but certainly not in repairing the situation. Some 20,000 items, medicines, raw materials, equipment, spares, vaccines, laboratory resources, and supplies, were brought into the country, and there were programs except in the north controlled by the government of Iraq. And this did bring about I think a significant improvement in the availability of food, medicines, vaccines, and nutritional goods, but made no impact on the investment deficiency, which has already been referred to.
So that was the background, more than a decade of deterioration. Some amelioration since 1996 through the Oil for Food Program of some of the basic deficiencies. But the system continued to be chronically under-invested, as has already been explained.
What is the situation now? I can add a few comments to the comments that have already been made. The system is extremely fragile. It's perhaps operating at 30-50 percent of its capacity. In that sense, access to basic health services and access to basic health systems services are severely compromised for a large part or the population.
As you've heard, this is not just due to the background factors, but also to sabotage, to looting, to chronic insecurity, to the lack of resources for running the essential recurrent expenditures of the system to very poor communications within the country, and to allow clarity about roles and responsibilities, who is in charge of what, who takes decisions for what.
So the common situation for the population as always, bears most heavily on the poor and on women and children. The public health situation is deteriorating again with increase in child morbidity, child diarrhea, poor management of pregnancy and delivery. Vaccination has just restarted last week. Communicable disease control remains powerless. The capacity of the public health system and the public health laboratory system to identify and control communicable disease is powerless.
There are significant environmental health threats, for example, from unexploded ordinances. And there is very substantial mental trauma in the population, as always in this situation, which needs to be identified and responded to.
WHO is one of a number of United Nations and other partners. The Iraqi partners have already been referred to in terms of Iraqi governance and professionals. And I'll come back to those. The Coalition Provisional Authority, the various elements of the United Nations system, the non-governmental organizations, and of course the donors, of which USAID is a most and possibly one of the most significant contributors.
WHO, like most of the UN agencies, has had an operational presence in Iraq for a number of years, right through the last decade and before, during and now subsequently after the war. And as a global public health agency, our primary role is to try to provide public health leadership and public health coordination in collaboration with our partners in this situation.
We will take a number of strategic approaches. One is the continued coordination of immediate humanitarian assistance. As you probably know, on Monday the United Nations launched a revised flash appeal for humanitarian assistance for Iraq, going from now through to the end of the year, in a figure of around $250 million, of which there was a significant component for immediate health assistance.
We have also, since the outbreak of the war brought very substantial amounts of resources and supplies into the country through the Oil for Food Program, which is now coming to an end, but there has been a great deal of activity over the months, and in WHO's case, some $180 million's worth of supplies have been brought in during this period.
The next strategic approach would be to work with the Ministry of Health, which needs substantial investment and development. It must be said it's something of a shell right now. With the governant departments of health and with our partners in terms of getting the basic essential medicine supply system working again, in spite of what I said about the Oil for Food Program, there has been an interruption in the pipeline of several months, and therefore the essential medicine situation is powerless.
The reinstitution of essential public health, in terms of disease surveillance, immunization, public health approaches to tuberculosis, to malaria, to other major communicable diseases, is an absolute priority. In terms of surveillance, analysis, information, communication, public health laboratory support, and all that is needed to simply get basic essential public health systems going. And I would add in that context the vital importance of infrastructure support, in terms of water, sanitation, and electricity, which has already been referred to.
The next strategic approach would be to try to get basic essential primary care going in terms of essential programs, such as maternal and child health and the availability of essential drugs. And then beyond that, to try in a way--we have used the term, 'jump-start'--to try to kick-start the secondary and tertiary care services. As has already been said, this was a reasonably well-developed health system. There is a substantial population of people with chronic disease that need drug or in some cases high-technology interventions, and it is necessary to think now about how they can be served.
And then the last strategic approach I would mention will be longer-term approaches to planning, to reconstruction, to human resourcing, to financing, so that in due course within the overall budgets, the Iraqi budget, the budget for 2004, which the CPA is currently working on, we can look to see a long-term sustainable health system emerging again in Iraq.
For WHO, the challenges are right now to be present in the country. I think that we are, both with international and national staff, well distributed across the country, to focus on assessments of the condition of the public health infrastructure and the health system infrastructure, to provide public health analysis, information, and good public health coordination. Those are our immediate challenges in association with all of our partners.
I think, for example, the colleagues in USAID have distributed a brief note of USAID activities, and you will see WHO mentioned on several occasions. And I think the points that are contained are consistent with the strategic approaches that I have identified.
The challenges. Well, the secure working environment has been mentioned. It must be stressed. It's been said already that many Iraqi health workers, particularly female workers, simply do not want to come to work at the moment. They don't want to come out onto the streets, they don't want to travel to work. So the provision of a secure working environment is extremely important.
Coordinated needs assessment, looking to the medium to long-term. On Tuesday in New York there was a large meeting between the UN parties and the World Bank with the presence of the CPA and member states and donor interests, setting out a coordinated approach to needs assessment, right across the sectors between now and what is potentially an international donor conference some time around October. Health will be one of the major sectors in that needs assessment. And WHO will be playing a very full role in that.
I referred already to partnership with Iraqi interests, both governmental, political, administrative, and professional. The CPA, the rest of the UN system, colleagues from UNICEF, for example, and UNFPA, that we have primarily worked with in the health field, but also right across the UN system and nongovernmental organizations.
A final comment would be the importance of recognizing a voice for Iraqi professionals in this process. Health professionals. They come from a distinguished educational tradition and a substantial level of competence. But they have been cut off from international contact for a very long time. And as often in this situation, one of the things they most crave is re-entry into the international community, and re-entry into normal international professional contact. And that's something that we will certainly be attempting to do our part to facilitate.
And lastly, I would say the importance of focusing on the re-emergence of predictability. Operational predictability. Financial predictability. Human resource predictability. It is a very fluid situation at the moment, and to re-establish some form of predictability as quickly as possible is an absolute priority.
Madame Chairman, thank you very much.
MS. PETERSON: Thank you.
I'd now like to turn us over to a colleague from ABT Associates, who can speak to the overall objectives of their program and some of their initial implementation efforts as well. Thank you.
MR. GOULD: Good morning. I'm Jeff Gould, and I'm stepping in for George Lodato, who wanted to be here but was called away for something else.
I can't provide you the same in-depth knowledge that he does of the whole program. But as the project manager, I can give you some insight as that what we're doing. Obviously we're there that help strengthen the Iraqi health care system. This has been, to say the least, rather interesting, with the team that has already arrived there, starting about the 1st of June. Their entrance into Baghdad was quite interesting, the way they had to go through the same process, as everyone else probably knows who has sent people into the field, is quite rigorous at times, as well as demanding and hazardous, as far as going into a place that is very fluid for security reasons.
We, ABT, is approaching this through six technical areas. Health care delivery; health policy; health practice; resource mobilization, behavior change, and one other one that I can't remember, but if you get back to me I'll get it to you later. These teams are set up to work not in a priority of which one is most important but which one they can get to first. And right now we have a team in the field working with resource mobilization. And one of our subcontractors, Health Sources Engineering, is there, looking, starting the process of going out and assessing primary health care clinics and hospitals.
For example, out of this we'll able to determine what is necessary to put these institutions or clinics, or hospitals back in good operating order. To that end, in our contract we have a line-item procurement of about $15 million and some of this will flow into that activity. This would also include medical devices, equipment, furnishings, and pharmaceuticals.
The other area that we're in right now is community. I think the one I missed was community development. And we have a technical team member that that's working on the field. He's been in Basra. We've also been up in Mosul to look at offices up there, as other areas to expand into quickly where we can work where it's permissive. So Basra and Mosul were two areas that we are looking at right now, as well as a home base in Baghdad.
The team did move out of the Al Rashid Hotel and into a small hotel where they feel the operations are easier for them, and less restrictive. Obviously, I'm more field-oriented in this sense. But as time has gone on in the last month, their concern, as we see from the e-mail exchanges, is security, especially in the last week or so, there's more shootings and more attacks against the military. So one of the things that's popped up very quickly is vehicles. And among the vehicles, is armored vehicles. Which is just from another point of view is a budget-buster, if you start looking at the prices of armored vehicles, depending on the level of security, anywhere from $100,000 to $250,000.
This is a real concern for ABT, because we value our employees, we value the people that we're putting out there, and realize this is a concern being shown in the field. And I'm sure others have heard of this too.
We are moving out of our initial phase, and we have to approach this with two phases, an initial phase, and then an implementation phase. As of May-June we're moving out of the initial phase and more into an implementation phase now, and from July through next April. We are planning as our TSOs are approved, what we call technical service orders, as this process is approved by AID in the field, which can be difficult because we are working between Baghdad and AID, the AID team that is in Kuwait City.
Once these are approved, we would expect to have quite a few more people in the field by middle of late July. As I mentioned already, we have two teams going in. Let's see, HSE is there, in Baghdad right now. There will be a support team going into Basra later this week to start the process of looking at hospitals there. We have some of our own people going in this week, working with resource mobilization. And then we'll have probably an economic group going in in early July, as it's looking right now.
I can't really be more forthcoming as far as what is happening, because it changes almost from week to week as to where the team leader, Dr. Mary Patterson, can see where advances can be made and where we can apply our effort in a way that's conducive to meeting AID's objectives and goals and strengthening the health system.
We would anticipate that for procurement purposes that most of our procurement needs would be determined probably by the end of July or early August. And from there we would like to think we'll be in full-scale implementation. We'll have approximately about 10-12 TA people in the field at all times with technical support from eight subcontractors. Each one is specialized in what they do. So it will be a very, very busy time, once we get everything set, as far as the TSOs and the needs that are going to be met under the TSOs. And then teams will start flowing in.
I apologize that I can't give you a more comprehensive overview. But that is about where ABT is at right now.
To follow up on this, please contact me at ABT, and I can probably give you much more detail for questions that you may have.
MS. PETERSON: Thank you very much.
We also have Dr. Carroll DeRoy with us, who is the Project Director for UNICEF in Iraq. And he will be available as a resource during the question and answer period, as well. So what I would like to do now is open it up to questions and answers.
We are actually broadcasting this session live on the web, as well, for the benefit of those who cannot be here physically. And so I would ask if people could please step to the microphone and identify themselves, speak into the microphone, so that those who are not physically present can still be part of the discussion. So, please.
QUESTION: Tony Pipps. I'm wondering how the current health care professionals in the field are getting paid for their work. If the ministry of health has deteriorated at the central government level, how are the funds flowing to the health care system right now?
MS. PETERSON: Uh-huh. Various civil servants, health care workers are receiving salary payments, as has been highlighted in various media coverage elements. But I'm wondering if the World Health Organization and/or UNICEF, even, and given some of your work with the Ministry of Health, can highlight some of the resource flow issues and status of the some of the personnel there. Dr. DeRoy?
DR. DEROY: My name is Carroll DeRoy. I've been in Baghdad for the last two years, came out on the 18th of March, back in on the 1st of May. And should be traveling back tomorrow.
Regarding the question of the salaries, it's been very slow for the civil service generally speaking. All sectors. Very slow payment of salaries. And that has not made it easier for the administration, the civil service to get back to track. But as serious is the fact that the current budgets are still in the making and have not been allocated either. So there is at this point in time, with possibly very few exceptions, no ministry which has money to cover the cost of fuel or all kinds of recurrent needs.
Plus of course the fact that the great majority of the ministries have been looted, burned down. And the physical space for the civil service to operate at this point in time is very deficient. Typically one would have ministries operating in makeshift buildings with capacity for maybe a third or a quarter of their staff.
So, the situation is not easy at this point in time. I hope that covers your question.
MS. PETERSON: Please.
QUESTION: My name is [Inaudible]
MS. PETERSON: I'm sorry, you'll have to some and speak into the microphone. I apologize.
QUESTION: My name is Mohammed Tenamli. I was in Iraq recently. And my understanding to the salary payment is CPA has devised a compensation plan that has six grades. And when I was there about three weeks ago, I understand many ministries have been paid. And the source of funding was the unfrozen assets that were frozen in the United States. So my knowledge is that civil servants have been paid.
MS. PETERSON: Okay. Thank you very much. And I should highlight that USAID is not involved in the payment of salaries compensation in that sense. Thank you.
Yes, please.
QUESTION: Hi. My name is Ross Anthony. I'm at Rand. And I guess I've got a couple of questions. One, has any health care worker been actually attacked other than maybe--I'm know we've seen military people targeted, but I'm wonder whether the health care workers have or have not.
MS. PETERSON: Okay. Any colleagues that want to speak to any events?
DR. DEROY: As far as we know, and the last time I spoke to Baghdad is about an hour ago, there has until now been no attacks on civilians on the UN, on any that is a humanitarian worker. All attacks so far have been targeted on Coalition forces.
QUESTION: I guess that gets me to my next question, and it really has to do with resources. I wonder whether or not collectively you all think there is enough resources to do the job. And as part of that is actually a feeling of mine, which I would appreciate your maybe commenting on. And that is that health care offers an opportunity for intervention in a very constructive way that oftentimes can be neutral or as neutral as possible to culture, religions, and politics. So it seems to me that it is an area that offers a real opportunity for much more aggressive action and larger commitments of funds and stuff than perhaps has been done to this point. And I wonder whether that is something that you all think is accurate, or you have other opinions.
DR. ALDERSLADE: I think that those are two very significant questions. On the subject of resources, obviously I'm not a person to speak of the CPA. But there were in the sessions on Monday and Tuesday some discussions about the resources. For example, I can confirm from those discussions the point that was made by the gentlemen in the back about the payment of salaries.
The person responsible in the CPA reported that the oil revenues this year will be about $3.5 billion and next year about $13 billion. I've referred already to 2003 as being an continuation and at the end of the year an ending of the humanitarian phase. There will need to be some sort of budget for 2003, but there will need to be a definitive budget for 2004. This will be a CPA responsibility. Into that will flow the oil revenues and revenues from the point that was made about assets, which may be ceased or may be unfrozen.
It will be a very important part of the needs assessment exercise, the coordinated needs assessment exercise that I referred to, to contribute at least a needs perspective to the needs side of the 2004 budget. And it will then be for the CPA to look at the revenues to try to come up with the priorities and to make judgements about social expenditure, including health.
We have done a few figures inside our own organization. I mean if you speculate, and I hasten to add this is only speculation. But if you said that the total budget for 2003 would be around $17 billion, and you took 6 percent, which would be a reasonable percentage of that total budget for health care, that only comes to about $45.00 per person in a population of 23 million people. Now, that's extremely powerless; that's relatively very low. It's hard, for example, to address some of the issues about adequate modern management of pregnancy and delivery at that sort of level of expenditure.
So I think we have to recognize that the resource available will continue to be an issue, and the perception that there is a vast cornucopia of oil revenue which will pay for everything simply doesn't look to be appropriate. That's why the continuation of the humanitarian appeal remains very important right now. And that's why the flow of international donor assistance, which hopefully will come from the consolidated needs assessment process through 2003 and 2004 will also be very important.
I hope that answers at least some of your first point.
Your second point is a substantial topic, which is: Can you use health, as you say, a culturally neutral vehicle, to promote dialogue and reconciliation, and to provide depth and growth in civil society within a society? And there's a considerable evidence that you can. And there's a substantial literature, that WHO, UNICEF, and other organizations have been involved in trying to develop this approach.
There are examples of successful practice in this respect, particularly, for example, in Central American and in Southeastern Europe, it has been possible to have fundamentally warring parties coming together around the table, around a health topic. Perhaps this is not the place to go into detail, but I'd be happy to talk to you afterwards.
But I think it's an extremely important point, and one that there was a certain amount of international experience, but there needs to be further attention and perhaps investment in this one.
Thank you.
MS. HERR: And I'll just speak quickly to your first point on security, since it was brought up. There was one attack that I know of, an ambush on health personnel early in April, from two health officers on the Disaster Assistance Response Team. And some of the attacks on the Coalition forces of the civil affairs people were on ambulances and vehicles that had the Red Cross symbol on them. And that was what they believed was being targeted, although there was no confirmation of that.
And I would just refer people who are interested in knowing about the security situation in Iraq to look for example to UNOCHI, or to CENTCOM. And there's a website, www.agoodplacetostart.org, which is the Humanitarian Information Center's website, hosts the UNOCHI security update weekly. In general, the major threats to humanitarian workers who are going in there tend to be car-jackings, people throwing stones, and that type of thing. And less so in the past two months, being under ambush or sniper fire.
Thanks.
MS. PETERSON: Thank you, Rachel and Dr. Alderslade. Yes, please?
QUESTION: Hi. My name's Mike Amatay [ph] of the Washington Kurdish Institute. Our organization has been looking at health factors and mapping sites in northern Iraq where there were confirmed use of chemical weapons. And over the past several decades, obviously there have been a lot of environmental problems that may very well contribute to some of the elevated cancers or birth defects or other factors which could be related to environment contamination.
And I'm wondering if there is any sort of comprehensive environmental assessment being planned for Iraq to see if some of the problems may in fact be caused by ongoing contamination or in fact long-term health effects of some of the conflict weapons, including land mines and things.
MS. PETERSON: Uh-huh. UNICEF or WHO?
DR. DEROY: I understand the United Nations Environmental Program, UNEP, has done a preliminary assessment on the environmental situation in the country. But going beyond the weapons and so far as looking at issues like sewage as well.
I understand also that the World Health Organization started or was in the process of establishing a protocol for a study on the impact of weapons and so forth. But I think there was a difficulty, this was before the war, because the government wanted the World Health Organization to focus on depleted uranium, and so forth. And the World Health Organization very wisely refused to focus exclusively on that. And they wanted to have a broad study looking at the broad elements of environmental contamination.
And that was the situation before the war. I don't know where we stand now. But definitely it is an issue which is important to take up again.
DR. ALDERSLADE: Well, just to say that it's a very important issue, and there are a number of contentious aspects to it. I think the situation at the moment is that now, immediately after the conflict, we would look and work with the United Nations environment program. It is normal after such conflicts, for example, after the conflict in Kosovo a few years, in which I was involved for a team from the United Nations Environment Program to do a comprehensive survey. As you say, I think a preliminary survey has been done.
The environment will be quite explicitly a cross-cutting issue across all of the I think 13 or 13 areas which have been decided between the UN system and the World Bank for the needs assessment process over the next few months. And I think that that is the right place for this, I recognize a very important concern and question that's been raised. But that is the right place for it to be addressed at the moment, I think.
Thank you.
QUESTION: I'm Ruth Walkup from the US Department of Health and Human Services, and am a member of an interagency working group that the state department is coordinating on environment. Environmental Health is one component of that. They are also looking at the reflooding of the marshes, river basin, water rights, in relationship to the other countries around Iraq; migratory birds; all of that sort of stuff. And they have someone on the ground, or have had someone on the ground with CPA as an advisor. That person actually came home here to Washington again, because he couldn't continue his work right now, because of the insecurity.
But there is a very coordinated effort on the side of the State Department and other agencies. They've got the US Forest Service and all kinds of different organizations and agencies involved in that working group.
MS. PETERSON: Please.
QUESTION: My name is Mark Rasmussen from the Academy for Educational Development. I had two questions, one specifically for UNICEF. What plans are being made now to address the malnutrition among kids under 5, that was mentioned as a critical problem?
And then secondly, per anyone, who is actually running the Ministry of Health in Iraq now? Is there an Iraqi Minister of Health? Is that being run by the provisional authority, or what is the leadership structure in the ministry?
MS. PETERSON: Okay. UNICEF?
DR. DEROY: I'll try to answer the second one first. I mean there's been a lot of shift and changes of interim Iraqi ministers, and also within the Coalition Provisional Authority, as far as I recall--I mean I've been out of Iraq now for about ten days--Steve Browning was the Coalition Provisional Authority Senior Advisor for Health when I left. I assume he's still doing that. But there has been quite a bit of shift, both on the Iraqi side and on the Coalition Provisional Authority side.
Regarding malnutrition, UNICEF has been working on a targeted nutrition program since the early '90s and basically it's a program which conducts growth monitoring of children, some 85 percent of the children under 5 throughout the country through a network of, before the war 3,000 community child care units; currently we understand that some 2,300 are still up and running. We've got to get the other ones revitalized.
And through that system we managed to, working with the Ministry of Health, identify children who were moderately malnourished and severely malnourished. The moderately malnourished children were provide with high-protein biscuits, and the severely malnourished children with therapeutic milk in some 68 pediatric hospitals throughout the country.
Now, due to a series of problems, the provision of therapeutic milk has not been there for the last three years. Just before the war, UNICEF managed to bring in enough for three months and we distributed those therapeutic milk stocks, and the high-protein biscuits has been faltering also in terms of the supplies before the war
So while the system has been very good at identifying those children who need supplementary and therapeutic feeding, failures under the Oil for Food Program particularly by the government of Iraq to bring in the supplies in time, have not rendered this program as efficient as it could have been.
Now, we've managed to bring in high-protein biscuits and therapeutic milk, and we are with NGOs revitalizing the community child care units, and we hope to expand that to about 4,000 units, so we have a full coverage for providing therapeutic milk and high-protein biscuits to kids.
Now, this system is very, very important because that we suspect that with the liberalization of the economy in Iraq there is bound to be inflationary pressures, there is bound to be an increase in social disparities. Substantially, I mean one could have a great potential for increasing malnutrition.
So it will be very important to consolidate and strengthen this system. Secondly, it's also a system which could be used as targeting social services. Because we know which families have moderately and severely malnourished children.
MS. PETERSON: Thank you.
Yes, please.
QUESTION: Captain Jack Smith representing the Assistant Secretary of Defense for Health Affairs. Just one point of information regarding the issue of the interface with the Minister of Health. The current senior advisor to the Ministry of Health under the Coalition Provisional Authority is Mr. James Haveman, and has arrived in the country just earlier this month. He has on his staff several Iraqi-American medical professionals who are coordinating with their counterparts in the Ministry of Health, and I don't believe that a new interim Minister of Health has been named at this point. But Mr. Haveman is currently heading that effort.
MS. PETERSON: Thank you very much for that clarification.
Highlighting the fluid situation in country. Thank you.
Please.
MR. COOK: Gary Cook from AID. Just another follow-up on the nutrition question. And that is that one of the things that USAID has asked ABT Associates to do is to look into the issue of food fortification. At this point food fortification is not prevalent, but there is a lot of potential for that. And I think there is a good opportunity for ABT Associates to work successfully on this.
MS. PETERSON: Thank you, Gary, for highlighting that.
QUESTION: Hi. I actually had a question specifically for the gentlemen from ABT Associates. And I know you've asked companies to register on your website and declare their capabilities. I was wondering if you could speak to how you intend to respond to that, and if you have a good time table in mind.
MS. PETERSON: You'll need to speak into the microphone.
MR. GOULD: We've been overwhelmed, more or less, by the amount of the number of inquiries concerning provision of technical services, procurement inquiries. Just about everything you can imagine has come in through the door for us. We have a system set up where the inquiries come in. And as they come in, I would think, within two to three weeks, you should have a response. If you don't, I would get right back to us. I, myself, am taking calls and responding to calls within a day. Or within 24 hours. Let's put it that way.
MS. PETERSON: Thank you. Just to reiterate, we would like to focus on implementation issues in this session, and any issues on procurement processes, sub-relationships, et cetera, can please be addressed outside this session.
Any additional questions, please? No. Okay. There are no additional questions. Okay. I should just caveat, not just questions, but input. We view this as a consultation too. So any input that people want to provide in addition to just inquiries we would welcome that, please.
QUESTION: I have two questions. My name is Anita Detarum [ph] also from Rand [ph]. The first question is: If somebody could speak to what the military health personnel are doing there specifically that's different from the organizations represented here. And prior to recent conflict, you know, we were aware that mortality rates, malnutrition, differed between the north and southern and central Iraq, so I was hoping that somebody could speak to how the response has differed between those regions.
MS. PETERSON: In the regions. Okay.
My colleague from DOD, would you like to address the first question?
MR. : Well, I'm not sure that I have the full answer to that. I can tell you that there are military units out in Iraq, obviously who's primary mission is the care of the military units there on the ground. I can tell you that they have cared for people with life, limb, and sight-threatening conditions. But they are not currently getting out and trying to provide any primary care. So it's primarily emergency response that they're providing some assistance with. But we have very limited infrastructure there. So we're trying hard to work with the existing infrastructure and build up the Ministry of Health.
MS. PETERSON: Thank you very much.
And my colleagues related to the various implementation efforts in the different geographical regions. Could you address that? Thank you.
DR. DEROY: In the mid-'90s the situation in old Iraq was substantially worse than the situation in south center, regarding mortality, as well as malnutrition and so forth. Thanks to the Oil for Food Program in the north, which was implemented directly by the UN agencies, the situation improved considerably in the north to the point that it became much better than the statistics in the south center. Now, not because the UN agencies are so good, vis-a-vis the government of Iraq in the south. We have to be realistic and modest here.
But the first reason is that 30 percent of the Oil for Food resources were allocated to 13 percent of the population in the north, while 59 percent of the resources were allocated to 87 percent of the population in the south center. So that's the first reason the per-capita investment was higher.
Secondly there was a cash component in the north, and the absence of a cash component in the south center severely limited the impact of the Oil for Food Program in the south center. Why was there no cash component? Because although the security council had approved a cash component, there never was an agreement between the Sanctions Committee, the 661 Committee, and the government of Iraq as to the modality of its use. The government of Iraq wanted the cash to be deposited in the bank of Iraq, while the Sanctions Committee said "No, this has to be allocated to the UN as is done in the north."
So, there never was an agreement; there never was a cash component. Thus, the overall efficiency and effectiveness of the Oil for Food Program in the south center was drastically less than it was in the north.
Examples: In the north we could, for example, rehabilitate primary health care centers, rehabilitate schools. We could train teachers, train nurses and water operators. All of that could not be done in the south center because of an absence of a cash component.
So just before the war and definitely today, the social indicators in the north are considerably better than in the south. That does not mean that the situation is ideal. And with the assessments being done now, we're looking at the country as a whole, and we will have to see what has to be done in terms of providing additional support to the north, as well as the south center.
But, one can assume that particularly in the extreme southern parts of the country, the needs are greater than in the extreme northern part. And that also has to do with the environmental issues. In the south, the water is brackish, both ground and surface water. The soil is brackish. I mean the survival of people themselves is much harsher, much more difficult than in the north. The environment in the north is much more friendly and favors the self-sustainability of people.
So these issues will have to be looked into.
DR. ALDERSLADE: Very little to add, except to say that at the moment the sort of population-based data that you were referring to is not available. And it is a priority always in these situations, as I emphasize, to recreate a capacity for a population-based public health information and analysis. And that's part of the essential public health functions which I emphasized. But at the moment, from a normal demographic point of view, your question can't be answered.
Thank you.
MS. HERR: I wanted to respond to your first question about what the Coalition military is doing to help implement. When I was there I worked at the Humanitarian Operations Center out at Kuwait. And they have similar centers in various areas around Iraq. In Basra they have the civil military operations center. In Baghdad there's a place called the FORUM, which is essentially the humanitarian operations center with a new name. And the military has been helpful in offering their assistance to NGOs and implementing partners. For example, providing transportation for distribution of drugs, for distribution of people. They've offered some force protection; that is, security for any NGO organization that is willing to take them up on their offer. And of course, it was at the discretion of each of organization whether they wished to accept those kinds of offers or not.
In addition, I understand that they are now hosting events mostly in central Iraq for NGOs and contractors. The first one was for example in Hila. I think they were trying to do others in other areas around central Iraq to get NGOs out to these different areas, show them what some of the situations were in these areas, and encourage them to start working there, since a lot of the work has been centered around Basra and Baghdad and Mosul in the north, I guess. Or Arveel.
And they've had a lot of information on assessments. Of course they were the front line as they were moving up, and were able to get into areas the NGOs and other organizations were not able to get to. So they did a lot of the assessments of hospitals and these areas. Unfortunately they have a system which makes that information classified. And they've got people who are working actively to declassify that information. And they've made over 200 assessments of hospitals available to the NGO community, who are interested in that.
So that's pieces of what they're doing. They've said to me numerous times when they were there, "Our job is to help you, because as soon as we help you, you get going and we get to go home." So that's sort of been their attitude out there.
Thanks.
MS. PETERSON: Thank you.
QUESTION: I am Barbara Dredi from the American Kurdish Center. I had a question about, going back to the question on the Ministry of Health and who exactly is working there these days, and what are they doing. I'm not sure if I head a really clear response, or else maybe I missed something on that.
But in conjunction with that question is also the point that Dr. Alderslade had made about Iraqis needing to be involved in the process of reconstructing the health system. I'm wondering how Iraqi doctors and professionals are involved at this point in helping develop plans and policy, and if organizations like ABT are interested in recruiting people here who are Iraqi doctors or people in the country who haven't had the chance to contribute recently. How can they do that?
MS. PETERSON: Okay. Thank you. There are a few questions there. In terms of the clarification, there is a senior advisor as part of the Coalition Provisional Authority, working in the Ministry of Health, helping to reconstitute that ministry with the support from Iraqis in country, the diaspora community, et cetera. So that is the status there.
But if colleagues could speak to some of the other questions in terms of how some of the private sector, let's say health entities of doctors, et cetera, are engaged, and how we would like to tap into the expertise, possibly from outside of Iraq too, in this effort.
MR. GOULD: ABT is actively recruiting Iraqi Americans or Iraqis who are here in the United States and with health backgrounds, and would like to go back under assignment with us. To further that, my phone number is (301) 718-3158. My e-mail address is Jeffrey_Gould@abtassoc.com. And we have an active component for recruiting Iraqi Americans, or Iraqis that are here and would like to go back and participate in the strengthening of the health system of Iraq.
DR. DEROY: I'd just like mention that the Oil for Food Program is coming to an end on the 21st of November, which I think overall is very good, because it's also indicating that the sanctions are being lifted, and that the country is coming back to normalcy. But it does have implications in terms of many, many Kurdish colleagues in the north of Iraq probably losing their jobs. I mean there are many Kurdish colleagues in the health sector, water, education, and other activities, who with the withdrawal of the United Nations from the direct implementation of the Oil for Food Program in the north, they will get into the job market.
So just to keep in mind that there are opportunities there also of employing Kurdish colleagues, highly qualified, who know the country, who know the situation on the ground, who've been there throughout, and who could possibly be less costly than hiring colleagues from here.
DR. ALDERSLADE: Yes. If I could just add one or two points. I think one shouldn't at the moment overestimate the capacity of the Ministry of Health to engage in any sort of systematic forward thinking about the development of the health system. I simply don't think that that's possible from the reports of those of our staff that are there or have been visiting there recently. And as I said in my introductory remarks, that is a real propriety, to re-establish both at central and at governant level the capacity to think strategically, systematically, about the future sustainable Iraqi health system is a real priority.
Like UNICEF, like the other UN agencies, we have for a long period employed Iraqi nationals, and continue to do so. And we are recruiting Iraqi health professionals to help us in the work that I outlined to you.
It is very important, when one started to think about what a sustainable Iraqi health system will look like in the future, to talk that through with Iraqi political, administrative, and professional interests. One can think of previous experiences where if you don't get this right, if you don't actually systematically involve them and bring the local people who must make the system work in the future with you in this process, you're unlikely to succeed.
And again, I emphasize that point, and I'm happy to do it again now. One can't simply parachute a model health system into a society; one has to take it from the bottom and take the local people with you, facilitating, encouraging, and promoting a dialogue and discussion. In that, I think it is very important, particularly in the frankly, possibly, rather powerless resource situation that we've already discussed, to think systematically about a constructive role for the private sector. And we would certainly intend to do that here.
Thank you.
QUESTION: Hello. Kadi Chumajidian [ph] with the ANE Bureau. I wanted to ask if possibly we could talk about just sort of following up on the last speaker, the role of nurses. And I understand in some of the meetings I've been sitting in that there are plans to have a national conference, and I'm wondering if the organizers could perhaps give an update on that activity, because I think it's very important, both to look at how the health sector can be used, and clearly in this particular case, looking at how to role of nurses as the reconstruction efforts role out.
MS. PETERSON: Good. Thank you.
DR. ALDERSLADE: Well, I absolutely agree with you. And the development of modern approaches to nursing and midwifery, and the empowerment of nursing and midwifery. And a forward-thinking approach to the contribution of nurses and midwives in a modern health system is something that needs, I emphasize the importance of talking to professionals, I didn't just mean doctors in that, I think that's fundamentally important and something, axiomatic that we would pay attention to that. I can only support everything you said.
MS. PETERSON: Okay.
MR. GOULD: ABT will be involved with a nurses' conference in July. Right now there is some ongoing discussion about the scope and the breadth and how many people will be involved, or will it be with a lot of nurses invited? Or will it be more of a tight-knit group at first which will then lead toward a nationwide conference on nurses at a later date? But in July there will be something.
MS. PETERSON: And just to clarify, in Baghdad?
MR. GOULD: Right.
MS. PETERSON: Right. Okay. We're close to the end. But we can probably accommodate about one more question, if there is one.
Otherwise, we would just like to thank very much our partners who took the time to speak and provide valuable information to all of us on realities on the ground. And thank you all for coming.
[End of proceedings.]
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